“You Can Change the World With a Haircut”: Evaluating the Feasibility of a Barber-led Intervention for Men of Black and Ethnic Minority Heritage to Manage High Blood Pressure

Background: People of Black, Asian and minority ethnic (BAME) heritage have a higher-than-average incidence of, and mortality from hypertension and stroke. Therefore, it is important to identify new settings for engaging people at risk of high blood pressure (BP). Aim: This feasibility study aimed to evaluate if barbers in a London borough can support and educate men of BAME heritage to manage their BP. Following UK Medical Research Council guidance, the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework was used to guide study objectives and feasibility outcomes. Methods: We collaborated with 8 barbers who were part of an existing BAME barber network. Barbers were trained online (1.5 h) and face-to-face (3 h) to provide BP healthcare advice and take customers BP readings. Qualitative field notes were collected to assess how best to recruit and train barbers, and to understand how to maintain motivation and retention of barbers. BP readings were recorded between June 2021 and March 2022. Results: Both online and face-to-face training were effective, however, greater focus on how to start conversations about BP with clients was needed. We found that motivation, incentivization and regular contact with barbers were important for recruitment, retention, and sustained BP measurement. Obtaining BP readings was challenging due to client concerns about recording their data and the impracticalities of recording results. We captured 236 BP recordings, of which 39 (16.53%) were over 140/90 mmHg; of these, 5 were over 180/100 mmHg. Conclusion: The combined data showed that educating barbers to take BP readings and deliver healthcare advice about BP is a viable intervention for rollout in a large-scale study. It has demonstrated the need to identify strategies to motivate barbers for sustained recruitment and retention, as well as further efforts to build trust among customers for long-term BP surveillance.


Introduction
Hypertension is a major public health concern due to its worldwide high prevalence and increased risk of cardio vascular disease and kidney disease. 1 However, people of Black, Asian, and Minority Ethnic (BAME) heritage in the UK are disproportionately affected by incidence of and mortality from hypertension and stroke. 2 The reasons for this are multifactorial. However, a lack of awareness and poorer engagement with traditional healthcare settings are potential contributory factors. 3,4 Evidence further suggests that AfricanCaribbean men have less frequent contact with 1 London South Bank University, London, UK 2 Croydon BME Forum, Croydon, UK the health care system compared with black women and thus lower rates of hypertension detection, treatment, and control. 5 One potential explanation for the lack of Black men receiving treatment for hypertension is the overall dis trust for health care systems and research. 6 It is therefore important to identify new settings for engaging people at risk of high bloodpressure who do not frequent usual health care.
Health promotion in partnership with barbershops has proven to be an effective strategy to reach populations most at risk of health disparities and build trust among minority communities. 7 Barbershops have been successful venues for health professionals to deliver health promotion and disease prevention for prostate cancer, HIV testing for Black men, and sexual health education among BAME communities. 812 Recently, Victor et al, 13 conducted a randomized controlled trial enrolling black male clients from blackowned barber shops assigned to a pharmacistled intervention for blood pressure control and management. The barbershop inter vention found that at 6 months, mean BP fell by 27.0 mmHg in the barber plus pharmacist group and by 9.3 mmHg in the barberonly group. The mean reduction was 21.6 mmHg greater with the addition of the onsite pharmacist. A BP of less than 130/80 mmHg was achieved among 63.6% in the barber plus pharmacist group versus 11.7% in the barber only group (P < .001). However, previous research indicated that higher and more sustained customer participation in bar bershop BP monitoring can be achieved when delivered by barbers compared to research personnel. 14 Therefore, it is the trusting relationship that barbers have with their clients, that lends itself to an intervention delivered by barbers.

Aims and Objectives
Barbershops have been effective venues to promote sexual health and HIV prevention among ethnic minority groups, and also for promotion of blood pressure awareness and control by community nurses in barbershops. 15 However, to our knowledge, no studies have evaluated the feasibility of delivering a barberled intervention for hypertension among BAME men in the UK. Historically, barbershops in African American communities have been an important cultural institution 16 and are therefore a culturally and contextually appropriate establishment to reach men of BAME heritage, providing a novel setting to address health disparities. Therefore, the aim of this study was to assess the feasibility of a barberlead intervention to support and educate men of BAME heritage to manage their blood pressure in Croydon, London.

Methods
As recommended by the Medical Research Council, 17 the REAIM framework 18 was used to determine the feasibility of implementing the Barber Blood Pressure Project, a bar berled health intervention for BAME men at risk of high blood pressure. The project was a multisite, singlecohort feasibility project conducted between January 2021 and March 2022.
We engaged with barbers to discuss the study setup and intervention delivery supported by members of the Croydon BME Forum (https://cbmeforum.org/) and Off the Record (https://www.talkofftherecord.org/). This support included coproduction of intervention, identification of barbershop sites, and liaison with barbers. Our project team comprised one project manager (7 h/week), one individual for barber liaison (3 h/week), the CEO from the Croydon BME Forum and an academic kidney nurse. The intervention was com plementary of the existing community healthcare program offered by the BME Forum (https://cbmeforum.org/the wellnesscentre/).

Recruitment
Barbers (n = 8) from an existing BAME mental health bar bers' network in south London, UK, were approached and conveniently recruited from 5 local barbershops, selected on location and positive response to invitation. In 2017, Public Health England 19 estimated hypertension in adults over 18 years in Croydon to be 23.8%. The borough has a diverse population comprising of 18 ethnic categories, with 8.6% identifying themselves as AfricanCaribbean and 6.8% as Asian.

Intervention Procedures
Due to the impact of COVID19, the project was delayed, and barber training commenced in February 2021 with the hope that barbershops would reopen in Spring 2021. Following UK government restriction guidance, barber shops reopened in April 2021.
Training Part 1 took place in February 2021 online via Zoom and consisted of: the background to the project, the barber's potential involvement, and discussion about the barbers' input into the intervention and anticipated consul tation time per customer. There needed to be an opportunity for barbers to have a realistic overview of their expected commitment to the project, an opportunity to ask questions and understand the benefits for their clientele. Training Part 2 was scheduled for April 2021 and was conducted in person. The barbers were taught how to approach clients to participate and offer BP checks with each haircut to eligible customers: males over 18 years of BAME heritage. Barbers were taught how to measure and interpret BP, record BP readings, and encourage clients to seek further healthcare advice where appropriate.
Barbers were advised to put the A2 BP poster in their shop window to attract footfall and promote the project within their communities. Barbers were provided with client cards to distribute BP advice to customers, with space to note 4 consecutive BP readings. Barbers were also provided with notebooks to record clients BP readings. It was diffi cult to define a target number of BP readings, but it was initially assumed (prepandemic) that each barber would have between 10 and 50 clients per day, dependent on the number of barbers in each barbershop.
The barbers were contacted fortnightly via telephone and WhatsApp to remind barbers to forward any BP data collected from clients. Where possible, barbershops were visited inperson fortnightly. Incentives for barbers during the project included training programs, networking oppor tunities, awareness of grants they could apply for, and social media training.

Data Collection
Qualitative data were obtained from observed interactions as field notes throughout the project. Field notes were collated from liaison with barbers and stakeholder organizations, informal discussions with barbers, discussions with stake holder organizations, interactions via WhatsApp, telephone and email, and when relevant observable actions occurred. Field notes, although underutilized in research and innova tion projects, 20 which provide a rich understanding of the context of intervention outcomes. 21 Informal discussions were conducted with barbers at fortnightly site visits.
Preliminary quantitative data were collected to assess the number of blood pressure readings recorded by barbers and the blood pressure values of clients visiting barber shops. Barbers maintained a handwritten record of client BP readings and shared data with the project team fort nightly via WhatsApp images.

Feasibility Outcomes
The REAIM dimensions were assessed independently using data qualitative and quantitative data collection. Table 1 provides an overview of the variables assessed under each REAIM component and the data source used to assess each variable.
The intervention was reviewed using qualitative data from field notes, site visits, and general observations.

Reach
In total, 8 barbers were recruited for the feasibility project. Five male barbers were recruited from the existing BAME Barbers Network WhatsApp group set up for a previous mental health project. Barbers were of African and Caribbean (n = 6), Greek Cypriot (n = 1) and Mauritian (n = 1) heritage and all had a large BAME clientele group.
By the project end date (March 2022), barbers had suc cessfully recorded 236 BP readings. Of the available record ings, 39 (16.53%) were over 140/90 mmHg; of these, 5 were over 180/100 mmHg indicating very high blood pressure. As no demographic data were collected from clients attending barbershops, it was not possible to ascertain the populations reached by the intervention.

Effectiveness
Overall, training was found to be effective both online and facetoface. Barbers particularly enjoyed learning about the practical elements of BP monitoring: using the BP machines and interpreting BP readings. However, barbers reported that there needed to be more focus on how to Barbers' views and feedback on the training provided Informal discussions and field notes Barbers' views and feedback on the project's effectiveness Informal discussions and field notes Acceptability Barriers and facilitators to barbers participating in the project Informal discussions and field notes Barriers and facilitators to clients participating in the project Informal discussions and field notes Implementation Extent to which the project objectives were met Barber data returns Degree to which the project activities were administers Informal discussions and field notes; observations Number and types of adaptions made to the project Informal discussions and field notes Barriers and facilitators to implementation Informal discussions and field notes Time and financial costs of the project Project team Maintenance Reasons for the lack of implementation Informal discussions and field notes; observations Resources necessary to guide monitoring and adaption of the project long term Project team initiate conversations with their clients about the project and BP health. Throughout the project, communication via WhatsApp and engagement with the project decreased. The project manager found that the level of engagement was higher with barbers when attending sites inperson and interacting on a onetoone basis. Although no barbers outrightly with drew from the project, only 2 barbers sustained consistent BP monitoring throughout the project. Four barbers did become demotivated and 2 stated they had more pressing priorities. As no followup data were recorded on the client cards, it was not possible to ascertain whether the project impacted the number of clients attending the doctors fol lowing BP monitoring and advice at barbershops. This is planned for a future project.

Adoption
Initially, barbers were optimistic about participating in the project. Intervention adoption was potentially limited due to the post COVID19 impact on customer numbers and reduced footfall, which resulted in fewer opportunities for BP monitoring. As a result, we provided barbers with incentives to boost motivation by informing barbers of available training, networking, and business development opportunities. The most effective training incentive was a social media and Instagram training workshop which 4 barbers attended.
Due to the ongoing COVID19 disruptions, project adoption among barbers was challenging. Barbers reported feeling anxious about the security of their business and whether clients would return as customers following lock down. We found that the motivation of barbers was a key factor in barbers adopting the intervention. During the train ing, one barber was particularly enthusiastic and said "you can change the world with a haircut." This same barber continued to demonstrate high levels of motivation through out the project and returned the highest number of BP read ings compared to the other barbers. One barber participated in a live Sky News interview, a success and a morale boost for all barbers to see their efforts on national television.

Implementation
There were several barriers to implementing the project. Although posters were created, not all barbers used them to promote the project as intended. While client cards were provided and designed for consecutive BP readings at each visit to the barbershop, barbers reported keeping the cards to note BP readings and giving their clients verbal advice instead.
COVID19 affected barbers' motivation to implement the project as they were concerned about their business, and some were also forced to seek work outside the sector. Feedback from barbers revealed concerns about annoying their customers by repeatedly asking them to participate in the BP testing. Barbers further reported that some clients were resistant to having their BP tested, with clients saying they did not feel ill and therefore felt they did not need their BP monitored. Barriers to recording all BP readings taken were partly due to clients' wariness in recording their data and the practicalities of writing or recording results.
Overall, the project was implemented as planned, with some minor changes. In Autumn 2021, the project lost momentum as barbers were felt demotivated. Therefore, additional funding was sought from a medical technology company to provide technical equipment to facilitate BP monitoring, and to provide additional incentives for barbers. Funding was approved in December 2021 and incentives (£5 per BP reading) were provided to the 2 barbers who initially demonstrated the highest level of engagement, then opened to the other barbers. The additional incentives proved effective and resulted in 189 (80%) of the BP read ings recorded by the barbers during the final 3 months of the project.
Regarding cost in time to barbers, it was clear that barbers were focused on their business. While the training sessions outlined to barbers that BP monitoring would take 5 min per customer and could be completed alongside a haircut, bar bers felt they did not have time to engage in the project or monitor BP readings. Additionally, a substantial amount of time was spent conducting fortnightly site visits and regu larly needing to followup with barbers for BP readings. Modest funding was provided to cover staff wages (project manager 6 h/week and barber liaison role 3 h/week), travel costs for site visits, meeting venue costs, and project resources. The intervention implementation cost was rela tively low: BP machines were £30 per machine and backfill time for barber's 1.5h training was £150 per barber attend ing both training days.

Maintenance
None of the implementation sites have formally continued to take BP readings at the end of the project, due to lack of funding. However, further funding applications to extend the project across other areas of the UK have been submit ted. The aim is to revise the barber recruitment process and training program (5 barbers in each location), understand the barriers and drivers to motivation further, ensure we reach blood pressure reading targets and track outcomes/ experiences of those recorded as having high/very high blood pressure.

Discussion
This study used the REAIM framework to evaluate the feasibility of delivering a barberled health intervention to support and educate men of BAME heritage to manage their blood pressure. We recruited 8 barbers who successfully recorded 298 BP readings from BAME male customers across 9 months. Several contextual and individual barriers to BP monitoring in barbershops, including COVID19 disrup tions and customer concerns about their data being recorded. Although engagement was sometimes inconsistent, we found that motivation was key to the intervention's success. Our most successful barbers had some connection to BP manage ment, either from lived experience or previous job roles.
Barbers faced unprecedented barriers associated with ongoing COVID19 disruptions hindering the intervention implementation. While barbers were initially enthusiastic about the project and the ability to positively impact other men of BAME heritage, a perspective consistent with pre vious barbershop studies 12,22 barbers soon became demoti vated. As such overall reach of the study was relatively low. However, consistent with previous barbershop studies, where incentivization resulted in positive outcomes, 14,23 the supplementary funding increased barber participation and BP monitoring.
Contradictory to previous studies suggesting that bar bers are wellpositioned in their community to facilitate trust around health promotion, 7 customers remained cau tious about having their data recorded. Additionally, feed back on intervention training indicated that more focus on facilitating conversation on BP monitoring was needed, which could also incorporate strategies to establish trust between barbers and customers, as previously demon strated. 10 Luque et al 24 provided a culturally sensitive "tool kit" to barbers delivering prostate cancer education, including brochures, posters, a DVD, talking points, and a community resource guide.

Limitations
This was a feasibility study with limited resources and, thus, several limitations. We only enrolled 8 barbers from one geographic location using convenience sampling from an existing BAME network established for a previous mental health intervention, which did not translate into high engage ment in the BP project. Consistent with feasibility studies, there was no control group included. However, previous research indicated higher and more sustained customer participation in BP monitoring was achieved when delivered by customers' barbers compared to research personnel. 14 Findings indicate that individual and contextual differences influence barber engagement and customers' willingness to participate. No demographic or followup data were col lected from customers, thus limiting the evaluation of the intervention reach.

Future of the Barbershop Blood Pressure Project
This was the first evaluation of the first iteration of the Barbershop Blood Pressure Project, a barberled inter vention to support and educate men of BAME heritage in managing hypertension in London. If positive findings from the current feasibility study can be further replicated in a multisite trial, this innovative approach to health care could serve as a novel model to prevent and treat men dis proportionately affected by cardiovascular and kidney dis ease. This evaluation provides the opportunity to address intervention limitations and strengthen the project's future impact before widespread dissemination and implementa tion. Recommendations can be found in Table 2.

Conclusion
The results of this study suggest that the delivery of a bar berled intervention may be a promising strategy to educate BAME men about BP and support the management of their BP. While our project begins to explore the training needs of barbers and the feasibility of implementing intervention on a small scale, future studies are needed to capture the potential benefits of barberled interventions for BP man agement. Future research should consider longitudinal studies to follow up with customers, evaluate the impact of a barberled intervention in managing BP among BAME communities and the sustainability of barberled interven tions. Given that the potential public health impact of this communitybased research is high, with thousands of blackowned barbershops nationwide, a barberled BP 1. Alternative strategies to increase the recruitment of barbers. Previous studies have found that stylists referred by influential community leaders reinforced the importance of delivering health intervention. 25 2. Identify a more sustainable funding source for incentives to increase retention and motivation of barbers long-term. For example, positive outcomes and sustainability in previous barber-led BP interventions were observed when providing financial incentives per BP reading and complete client card. 14 3. Development of a more reliable and efficient means to record BP data. Digital recording of BP may reduce time burdens for barbers; however, study teams should also consider issues surrounding mistrust and customers' concerns about having their data recorded. 4. Incorporate follow-up data collection to assess the effectiveness of the intervention. Follow-up surveillance of customers' BP monitoring will require careful consideration of strategies to recruit members of the BAME community for studies. 5. Future development of the barber-led BP intervention is conducted in collaboration with all relevant stakeholders to develop an effective and culturally sensitive health intervention.
intervention shows promise as a novel approach to reduce health inequalities among men of BAME heritage.

Author Contributions
NT: Principal Project Leader, conceived study, participated in design and coordination, read and approved the final manuscript. DLR and AB: Participated in design and coordination, read and approved the final manuscript. CE: Helped to draft manuscript and approved the final manuscript.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Partial funding for the study provided by the Bryant Healthcare Bursary.